A "low-risk" pregnancy in the Netherlands may actually carry a higher risk of perinatal death than a "high-risk" pregnancy, researchers found.

Action Points

Explain to interested patients that a "low-risk" pregnancy (supervised by a midwife) in the Netherlands may actually carry a higher risk of perinatal death than a "high-risk" pregnancy (supervised by an obstetrician).

Note that the study also found that women who were referred from a midwife to an obstetrician after labor began had an even greater increase in the risk of perinatal death.

A "low-risk" pregnancy in the Netherlands may actually carry a higher risk of perinatal death than a "high-risk" pregnancy, researchers found.

Under the Dutch system of obstetric care, women with low-risk pregnancies are supervised by a midwife in primary care, with the choice of a home or hospital delivery, whereas those with potential complicating factors are supervised by an obstetrician throughout their pregnancy and given a hospital delivery.

It turns out that, over a two-year period, infants born to mothers at low risk had a greater risk of delivery-related perinatal death than those born to mothers at high risk (RR 2.33, 95% CI 1.12 to 4.83), according to Annemieke Evers, MD, of the University Medical Center Utrecht in the Netherlands, and colleagues.

The increase in risk was even greater among women who started labor under the supervision of a midwife but required referral to an obstetrician (RR 3.66, 95% CI 1.58 to 8.46), the researchers reported online in BMJ.

According to Evers and her colleagues, the findings raise questions about the effectiveness of the obstetric system in the Netherlands.

"The Dutch obstetric system itself possibly contributes to the high perinatal mortality compared with most European countries," they wrote. "A critical evaluation of the obstetric care system ... is thus urgently needed."

The researchers analyzed data from 12 hospitals and 56 midwife practices in the area served by the University Medical Center Utrecht. Additional data came from a national perinatal register.

In 2007 and 2008, there were 37,735 singleton or twin pregnancies free of congenital malformations that progressed to at least 37 weeks' gestation.

The overall perinatal death rate was 2.62 per 1,000 babies delivered. Babies born to women who had never given birth before had a significantly increased risk of perinatal death (RR 1.65, 95% CI 1.11 to 2.45).

Although the rate of delivery-related perinatal death was higher among the women who were under the supervision of a midwife at the start of labor, NICU admission rates did not differ between the low-risk and high-risk pregnancies.

The finding that women who were referred from a midwife to an obstetrician after labor began had an even greater increase in the risk of perinatal death is of major concern, according to the researchers, and could be explained by delays at three moments during labor.

First, diagnosis of a problem may be delayed in primary care because the midwife might not be present early in labor, and fetal heart beats are checked only every two to four hours.

Transportation to a hospital also introduces a delay.

And finally, an obstetrician may underestimate the risk to a transferred patient because she was originally considered low-risk.

"These factors should be subject to further investigation, especially to evaluate whether complications with the potential to lead to perinatal death can better be predicted," the researchers suggested.

Wrote Derek Tuffnell, of Bradford Royal Infirmary in England, in an accompanying editorial, "Serious adverse events in labor are uncommon in any setting. Obviously, however, if such an event does occur, the further away from assistance a woman is the less likely the outcome will be good."

Evers and her colleagues acknowledged that the study was limited by the use of aggregated data from a large birth registry, which made it impossible to adjust for confounders and clustering. They noted, however, that adjusting for potential confounders would likely strengthen the results because certain risk factors -- older age, low socioeconomic status, and non-Western ethnicity -- are overrepresented in the "high-risk" group.

The study authors and the editorialist all reported that they had no conflicts of interest.

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